- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $2,951.21 / $6,165.95
| Professional | | $186.21 | $2,951.21 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $2,818.38 / $5,011.87
| Professional | | $257.04 | $2,818.38 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $3,019.95 / $6,606.93
| Professional | | $257.04 | $3,019.95 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $4,786.30
| Professional | | $32.36 | $33.11 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $3,019.95 / $6,606.93
| Professional | | $245.47 | $3,019.95 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $549.54 / $7,585.78
| Professional | | $245.47 | $549.54 | $7,585.78 |